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Cardiac catheterization: Is it needed?

STORY BY MICHELLE GENZ, (Week of August 23, 2012)
Photo: A cardiac catheterization procedure being performed at Indian River Medical Center.

A federal investigation into unnecessary cardiac catheterizations at Fort Pierce’s Lawnwood Regional Medical Center, along with New York Times revelations, may have a growing number of patients wondering how they can be sure – if told the procedure is needed – that it actually is warranted.

Heart centers are among the most profitable arenas in health care.  Angioplasty can cost around $20,000, of which Medicare reimburses hospitals about $10,000. For a diagnostic catheterization, Medicare pays $3,000.  

As a result, these programs have become increasingly competitive for patients.  While Lawnwood was an early leader in the lucrative heart business, Indian River Medical Center and Holmes in Melbourne were performing catheterizations well before they opened heart centers in 2006, and Sebastian River Medical Center opened a new cardiac catheterization center just this past April.

State data shows that for-profit hospitals did nearly 50 percent more catheterizations than non-profit hospitals, the Tampa Bay Times reported Sunday.  Lawnwood is a for-profit hospital; IRMC and Holmes in Melbourne are nonprofit.  No data for Sebastian River, a for-profit hospital, would yet have been included in the state report.

Last week, the New York Times reported that at Lawnwood, 1,200 diagnostic heart catheterizations – 50 percent of the total in a 2010 review – appeared to have been performed on patients with “no significant heart disease.”

“Short of having a physician in the family, it’s very hard to be a medical consumer,” says Dr. Jay Midwall, medical director of interventional cardiology at Indian River Medical Center’s Heart Center.

But Midwall and Jason Vance, IRMC’s director of cardiovascular services, outlined a series of processes put in place by the Heart Center – which is affiliated with the Duke University Health System – which they said should raise the confidence level of patients that “the doctors do the appropriate thing.”

“If patients worry, sometimes they hesitate in obtaining care and that can be detrimental to their health,” said Jay Midwall. “People should feel safe,” added Nance. “We have a lot of safeguards with the Duke oversight.”

In 2011, according to Nance, there were 1,500 diagnostic catheterizations at IRMC, and 475 stents inserted via angioplasty.

“When it’s elective, and it doesn’t have to be done that day, it’s always good to have an opinion from a non-invasive cardiologist,” Midwall said. 

Midwall says that layer is built into IRMC’s Heart Center. In terms of balloon angioplasty and stenting – not diagnostic catheterizations – the heart center is a closed clinic. Its doctors do not have offices outside the hospital and outside doctors cannot perform procedures there.

A catheterization patient would have to first be seen and tested by a primary care physician or a cardiologist who does not perform the procedure.  Those extra physicians are “another set of eyes” on the patient charts, according to hospital CEO Jeff Susi.

“This is adopted from the academic model,” says Midwall, who believes IRMC is likely the only hospital in the state with that policy, apart from university affiliated teaching hospitals.

“We’re the last dinosaur,” he says. “When I started practicing in Florida there were probably 40 programs that run like we do now. About four years ago, there were maybe three. Over the last 25 or 30 years, it’s gone in the opposite direction not for the best reasons, but for practical reasons.”

The New York Times reported that at three HCA hospitals in Florida, internal reviews uncovered a high rate of unnecessary catheterizations, when the percentage of blockage of the artery didn’t meet the accepted standard to warrant intervention.

But Midwall said IRMC data submitted to a national registry showed that all 475 interventions in 2011 were warranted. “There were only three that were possibly, at first glance, there was a question of why the intervention was done, and when we did a chart review we realized the data we submitted wasn’t complete. Later, reviewing the charts, the procedures were indicated, I’m proud to say.”

In addition, every quarter, Duke cardiologists fly in to examine random and specific cases as well as overall trends and data.

“It’s a tremendous experience,” said Midwall, who says he looks forward to the visits. ”It’s a lot of fun, believe it or not. We get to present all our data. If there’s a complication, we present it and see if Duke would have done any different. I’m happy to say sometimes they don’t know what they would do either.”

Indian River also submits data to a registry run by the American College of Cardiology that allows it to compare its numbers by doctor and institution to others in the area as well as regionally and nationally. He looks closely at the rate of “normals,” patients whose blockages were not serious enough to treat but who nonetheless received treatment.

“If you do too many normals, it suggests you’re not screening them carefully and you’re subjecting them to an unnecessary procedure, or, God forbid, you’re building up your numbers or building up your income.”

At the same time, he says, too low a percentage can mean patients needing treatment could be missed.  “If you’re doing too few normals, that’s not good either,” Midwall says.

“Once in a while you would take out a normal appendix because it was better to err on the side of safety rather than miss an inflamed appendix,” says Midwall. “The vast majority of physicians try to do their best for what’s best for their patients.”

Increasingly, experts question the use of stents when safer, cheaper pharmacological options may do the trick.

When the blockage is causing no symptoms, or the symptoms are stable, as in the pain of angina, treatment is elective. Increasingly physicians use drugs to open blockages after a 2007 Harvard study showed that in those stable patients, angioplasty did not prevent future heart attacks over the long term or lengthen lives any better than using medications and lifestyle changes.

But during a heart attack, catheterization with balloon angioplasty and stent insertion is considered the treatment of choice when a sudden blockage is the cause.

 “In general, it’s true that in an emergency you are at the whim of the doctors who you meet in the emergency room,” said Midwall.  “If that’s the case, you want to be brought to the institution that is rigorous in selecting the staff with processes in place to make sure the doctors do the appropriate thing.”